| Mechanical Therapy
for GERD
Heartburn and gastroesophageal reflux are
common problems in clinical practice. Significant advances
have been made in the diagnosis and pharmacologic management
of these conditions over the past 25 years. The etiology of
GERD is multifactorial, although transient lower esophageal
sphincter relaxations are thought to play an important role
in addition to poor esophageal clearance and weak lower esophageal
sphincter pressures (1,2). For many subjects with these complaints,
simple measures such as changes in eating, or weight loss,
can provide a significant benefit. Patients often have symptoms
despite these measures, or are unable to comply with these
recommendations and end up on medications. For those with
severe reflux, particularly erosive esophagitis, the proton
pump inhibitor medications seem to be the most efficacious
treatment (3-5).
In some patients, breakthrough symptoms
appear to occur. Medical therapy for these patients can be
complicated and expensive, and the best approach to these
patients is debated (5,6). Some patients are reluctant to
be on life long medical therapy. Patients with regurgitation
and aspiration can also be difficult to manage medically.
Surgery has played a role in the management of these patients
for many years, and the results appear to be efficacious.
However, patient selection appears to be important (7,8).
This issue of the Visible Human Journal of Endoscopy (VHJOE)
presents the following expert reviews: "Laparoscopic
Antireflux Surgery" b. Drs. Kellogg, Oelschlager, and
Pellegrini and "Endoscopic Antireflux" by Dr. Gostout
for an update on therapies that can be considered in those
patients in whom a mechanical approach seems warranted. These
mechanical therapies are directed towards the gastroesophageal
junction. As seen in Figures 1A and IB from Visible Human
data, the diaphragm and intrinsic esophageal musculature appear
to be important. For those who wish to examine the anatomy
of this region in more detail, please click on the link below
Figure 1A to view the Interactive Atlas image.
Regarding updates to the VHJOE, we soon
hope to provide a drop down menu to allow one to link to all
of our previously published expert review articles. We hope
this makes it easier for readers to enjoy VHJOE. I also want
to take this time to personally thank Dr. Peter McNally for
selecting the topics and authors for our Expert Review section
of VHJOE. I also want to thank Julie Giron for her excellent
work in laying out the current format of the journal.
References
1. Katz PO. Optimizing medical therapy for gastroesophageal
reflux disease: state of the art. Rev Gastroenterol
Disord. 2003 Spring;3(2):59-69.
2. Arora AS, Castell DO. Medical therapy for gastroesophageal
reflux disease. Mayo Clin Proc. 2001 Jan;76(1):102-6.
3. Berardi RR. A critical evaluation of proton pump inhibitors
in the treatment of gastroesophageal reflux disease.
Am J Manag Care. 2000 May;6(9 Suppl):S491-505.
4. DiPalma JA. Management of severe gastroesophageal reflux
disease. J Clin Gastroenterol. 2001 Jan;32(1):19-26.
5. Ramakrishnan A, Katz PO. Pharmacologic management of
gastroesophageal reflux disease. Curr Gastroenterol
Rep. 2002 Jun;4(3):218-24.
6. Cross LB, Justice LN. Combination drug therapy for
gastroesophageal reflux disease. Ann Pharmacother.
2002 May;36(5):912-6.
7. Allgood PC, Bachmann M. Medical or surgical
treatment for chronic gastrooesophageal reflux? A systematic
review of published evidence of effectiveness. Eur
J Surg. 2000 Sep;166(9):713-21.
8. Kahrilas PJ. Management of GERD:
medical versus surgical. Semin Gastrointest Dis.
2001 Jan;12(1):3-15.
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